Hemodynamic and oxygen transport monitoring in management of burns

Burn resuscitation has been performed predominantly by means of the Parkland formula for the past 25 years. Normalization of heart rate, blood pressure, and production of 1 mL/kg/hr of urine were proposed as suitable guides to resuscitation. Recently, it has become apparent that the standard circulatory criteria of fluid replacement adequacy are too inaccurate to produce optimal hemodynamic end points. Our burn team has reported a 4-yr experience with use of the pulmonary artery catheter inserted on admission to the unit of severe burn injuries. This monitoring device allowed for additional fluid volume administration to enhance circulatory function with resulting production of maximal hemodynamic values. The ability to achieve hyperdynamic end points predicted survival in our series. Use of invasive monitoring to produce hyperdynamic circulatory end points has resulted in a significant decrease in overall mortality. Oxygen consumption (VO2) was important and there was a statistically significant difference in this variable which distinguished survivors from nonsurvivors. VO2 increased progressively in relation to burn size in survivors but stayed at a constant lower value in nonsurvivors. Elderly burn patients were resuscitated at lower end points than younger individuals because of volume intolerance. Inability to be aggressively resuscitated results in twice the mortality in burn-injured elderly patients. These experiences indicate that burn resuscitation as currently practiced with existing formulas produces inadequate circulatory responses, and both survival and organ function can be improved by maximizing circulatory end points.